Reducing readmissions by empowering patients

St. Joseph Hospital in Whatcom County, Wash., reduced unnecessary readmissions by improving patient self-management after hospital discharge.

Where: St. Joseph Hospital, a 253-bed facility in Whatcom County, Washington.

The issue: Reducing unnecessary readmissions by improving patient self-management after hospital discharge.


The Centers for Medicare & Medicaid Services (CMS) was recruiting Medicare quality improvement organizations (QIOs) to pilot new methods of transitioning patients from inpatient to post-acute care. Led by Qualis Health, the local QIO, this Washington hospital and community volunteered to participate.

As part of the new pilot, the QIO brought in experts to provide training in Eric Coleman's Care Transitions Intervention coaching model, which focuses on managing medications, educating patients about “red flag” symptoms, ensuring follow-up care, and maintaining personal health records. “We recruited 40 various providers in the first year of the project, including home health agencies, Medicare Advantage Plan case managers, parish nurses,” said Selena Bolotin, a clinical social worker and manager of the pilot program.

These trainees made changes to their existing practices based on the education, but the pilot's leaders wanted to expand the program. They decided to recruit some community volunteers to be trained as transition coaches.

How it works

Volunteers are recruited through a community volunteer center and a nearby university. “While a number of our volunteers are retired nurses or have had some health care experience, we've also had lay volunteers,” said Ms. Bolotin. “Because it's not case management, it's not clinical care, [the program] allows a lay person who learns the model to be able to coach and empower patient and family members around self-management.”

After training, which includes 12 hours in the classroom plus on-the-job shadowing, volunteers begin by meeting with a patient (Medicare beneficiaries who are considered high-risk for readmission) in the hospital shortly before discharge. Then soon after discharge, the volunteer visits the patient at home. “A lot of the home visit is around medication management, but also checking in again on that follow-up visit with the physician,” said Ms. Bolotin. Volunteers ensure that patients have scheduled timely follow-ups, role-playing the conversation to have with a primary care office receptionist, if necessary. They also review medications, red flags and the personal health record.

Over the next few weeks, the volunteer calls the patient three more times, to make sure the transition is going well.


It's difficult to measure the impact of the program on readmissions to date, but the anecdotal evidence, and preliminary tracking of individual patients, looks positive. One patient had been hospitalized nine times in 13 months, but was able to stay out of the hospital for the next seven months after the intervention.

Some intermediate process measures collected by the project are also showing its effect. The coaching sessions have uncovered an average of 2.23 medication discrepancies per patient. The program also assesses patient activation before and after coaching, and has found that 75% of patients show greater engagement in their own care after the intervention.


Patient information and privacy were problems at first. Now, all volunteer coaches attend the hospital's usual volunteer orientation, during which privacy regulations are explained.

How others benefit

Volunteers, as well as patients, have been pleased with the interactions. “They get to have genuine interactions with patients and family members that make a difference,” said Ms. Bolotin.

Physicians who treat the coached patients, both in the hospital and out, have also reported benefits. “One example of that had to do with a complicated dosing protocol for a patient,” said Evan Stults, Qualis' executive director of communication. “When the patient got the prescription, the hospital staff and the physician thought it all made sense. But the patient went home and then the coach learned that the patient did not know what she was supposed to be doing. The coach went back to talk to the physician, and that was an eye-opener for the physician.”

Some outpatient docs have found interactions with patients to be more productive post-coaching, and others have appreciated the reminder of the value of patient education. “One physician said, ‘Wow, I should be asking all my patients if they know what the red flags are and talking about that,’” Ms. Bolotin said.

Next steps

CMS funding for the pilot ends in July 2011, but the program's steering committee is studying ways to sustain the intervention. “We are working actively with the Area Agency on Aging and the local university to consider the benefits of integrating the coaching program into case management services for seniors and providing a unique student experience,” said Ms. Bolotin.